Exudative Macular Degeneration Research Articles

Seeing you through London 2012: eye care at the Paralympics

BackgroundThe provision of eye care services for competitors and support teams is integral to the modern Olympic Games. The eye clinic for the London 2012 Paralympic Games employed a multidisciplinary...

Anti-VEGF response in macular hemorrhage and incidence of retinal pigment epithelial tears

ObjectiveTo study the visual and anatomic outcomes of serial anti–vascular endothelial growth factor (anti-VEGF) therapy for severe macular hemorrhage in eyes with exudative age-related macular degeneration (AMD). DesignConsecutive retrospective analysis. ParticipantsTwenty eyes from 20 patients with severe macular hemorrhage (greater than 50% blockage with formal fluorescein angiography [FA]) secondary to wet AMD were studied. MethodsWe performed a chart review of patients at a single centre from May 2006 to September 2009. Presenting visual acuity and diameter of hemorrhage were recorded as well as number of injections, time by which no hemorrhage was remaining, and final anatomic outcome. Cardiovascular risk factors and use of antiplatelet medication or anticoagulation were noted. ResultsAverage presenting visual acuity was 1.55 (20/710), and number of injections needed for resolution of hemorrhage was 4. Visual acuity significantly improved from 1.55 (20/710) to 0.70 (20/100) after injections. Thirty-five percent of eyes were found to have an associated retinal pigment epithelial (RPE) tear, and these eyes were found to have received more injections. Final visual acuity was not significantly different in eyes with RPE tears compared with nontear eyes. Eighty-one percent of patients had associated cardiovascular risk factors; antiplatelet therapy and anticoagulation were not found to play a role in hemorrhage size. ConclusionsRPE tears are found in a significant number of individuals with large macular hemorrhages secondary to exudative macular degeneration, but with continued treatment with anti-VEGF therapy, visual acuity can significantly improve even in the presence of these tears. Eyes with severe macular hemorrhage thus should be considered candidates for anti-VEGF therapy.

Macular hole overlying pigment epithelial detachment after intravitreal injection with ranibizumab.

To describe a previously unrecognized complication of intravitreal injection in a patient with exudative macular degeneration and vitreomacular adhesion. Case report of a 69-year-old woman. One month after intravitreal injection with ranibizumab for exudative macular degeneration, our patient developed a full-thickness macular hole with visual acuity of 20/100. After pars plana vitrectomy with membrane peeling and fluid-gas exchange, the macular hole was closed and the visual acuity improved to 20/60. Macular hole formation after intravitreal injection with ranibizumab is a potential complication that should be considered before treatment, especially in those patients with large subfoveal pigment epithelial detachments and vitreomacular adhesion. Although successful closure may be attained after pars plana vitrectomy, this potential morbidity should be considered when treating these patients. In addition to the already well-described tractional forces of the vitreous overlying the fovea, and the potential contractile nature of a choroidal neovascular complex in response to ranibizumab, a posterior pushing or stretching mechanism of a large pigment epithelial detachment may also contribute to macular hole formation.

Emerging roles for antiangiogenesis factors in management of ocular disease.

The first antivascular endothelial growth factor (anti-VEGF) was developed as an anticancer drug for colonic carcinomas. Since then, anti-VEGFs have developed in scope and indications. They have revolutionized the treatment of exudative macular degeneration and have had a major impact on treatment of several other conditions. This has resulted in an increased number of patients seeking treatment with new treatment options and has had a considerable financial impact on health care resources. Anti-VEGFs have been used in the treatment of all age groups of the population ranging from infants where it is used for treatment of retinopathy of prematurity to the elderly where it is used in exudative macular eegeneration.

Diffusion of Technologies for the Care of Older Adults With Exudative Age-Related Macular Degeneration

To determine patterns of diffusion of diagnostic tests and therapeutic interventions in the United States through 2010 for patients with newly diagnosed exudative macular degeneration (AMD). Retrospective longitudinal cohort analysis. SETTING AND PATIENT POPULATION: A total of 23 941 Medicare beneficiaries with exudative AMD newly diagnosed during 1992-2009. Current Procedural Technology (CPT-4) billing codes were used to identify use of diagnostic tests (optical coherence tomography, fluorescein angiography, and fundus photography) and therapeutic interventions (argon laser photocoagulation, photodynamic therapy, intravitreal corticosteroids, and anti-vascular endothelial growth factor [VEGF] agents) used by these beneficiaries during the first year following diagnosis. Rates of use of study diagnostic and therapeutic procedures. Diffusion was rapid for each successive new diagnostic and treatment modality, with use of newer procedures quickly replacing existing ones. The number of beneficiaries treated with anti-VEGF agents for exudative AMD was considerably greater than for prior innovations, rising from use in 4.0% of beneficiaries in 2004-05 to 62.7% in 2009-10. In each year from first diagnosis years 2006-2009 and in different practice settings, use of bevacizumab exceeded that of ranibizumab (60%-78% vs 33%-47%, respectively). Rates of diffusion of the various therapies were relatively similar in communities throughout the United States irrespective of presence of a major teaching hospital in the vicinity. Newer, more effective therapeutic interventions for exudative AMD diffused rapidly throughout the United States, quickly replacing older, less effective interventions. Although improving patient outcomes, rapid diffusion raises important public policy issues for Medicare and other payers to consider.

Nuevas pautas de tratamiento y seguimiento en pacientes con degeneración macular asociada a la edad exudativa

Intravitreal ranibizumab (Lucentis®) injections are the treatment of choice in patients with exudative macular degeneration. In the last few years, several treatment and follow-up strategies have been evaluated with the aim of optimizing the safety and efficacy of this drug. In routine clinical practice, the Pro Re Nata (PRN) and treat-and-extend protocols or variants of the FUSION regimen have been used. PRN protocols are based on regular patient follow-up and on retreatment when there is evidence of reactivation of the lesion, basically determined by loss of visual acuity and persistent or recurrent macular fluid on optical coherence tomography. Treat-and-extend or FUSION protocols are based on early retreatment of the lesion before reactivation occurs with the aim of avoiding the irreversible visual loss that can occur in disease recurrences.There is no ideal treatment and follow-up protocol that could be used as an alternative to the monthly regimen and be applied and reproduced in all patients. Consequently, intravitreal ranibizumab therapy should be individualized in each patient.

PILOT STUDY FOR THE DETECTION OF EARLY EXUDATIVE AGE-RELATED MACULAR DEGENERATION WITH OPTICAL COHERENCE TOMOGRAPHY

Optical coherence tomography (OCT) provides microscopic retinal images. Optical coherence tomography is noninvasive, using light waves to produce detailed retinal images. Here, we investigate the ability of OCT to detect early choroidal neovascularization in age-related macular degeneration. Seventy-nine patients, diagnosed with nonexudative macular degeneration in one eye and exudative macular degeneration in the other were enrolled in this prospective, observational, nonrandomized study. Participants underwent examination (visual acuity, intraocular pressure, biomicroscopy, and ophthalmoscopy) followed by OCT in the study eye (nonexudative macular degeneration eye) every 3 months for 2 years. If examination did not show choroidal neovascularization, but OCT images raised suspicion, patients were reexamined in 4 weeks to 6 weeks and/or fluorescein angiography was performed. Visual acuity, OCT anomaly detected, and time between OCT and fluorescein angiography detection were examined. Fifteen (19%) patients developed exudative macular degeneration, as confirmed by fluorescein angiography, in the study eye. Four additional patients showed potential exudative macular degeneration on OCT only. Of the 15 patients who developed exudative macular degeneration, 13 had disease progression identified on OCT before examination and/or fluorescein angiography showed changes. Subretinal pigment epithelium fluid was the most common OCT anomaly, with development of sub-/intraretinal fluid also visible. Optical coherence tomography could be a powerful screening tool for patients with age-related macular degeneration at high risk for developing choroidal neovascularization.

Anti-Vascular Endothelial Growth Factor Drug Treatment of Diabetic Macular Edema: The Evolution Continues

Diabetic mellitus is the leading cause of blindness in working aged patients in developing nations. Due to the buildup of abnormal metabolites from several overactive biochemical pathways, chronic hyperglycemia causes oxidative stress in the retina which upregulates vascular endothelial growth factor (VEGF). Together with other growth factors and metabolites, VEGF causes endothelial cell proliferation, vasodilation, recruitment of inflammatory cells, and increased vascular permeability, leading to breakdown of the blood-retinal barrier. This allows trans-cellular exudation into the interstitial space resulting in diabetic macular edema (DME). For over 3 decades the standard treatment for DME has been laser photocoagulation. Though laser reduces the incidence of vision loss by 50%, few eyes with diffuse edema experience improved vision. This has led physicians to use the VEGF-binding drugs pegaptanib, ranibizumab, and aflibercept, each of which has been approved for the treatment of exudative macular degeneration, and bevacizumab which is commonly used off-label for a variety of chorioretinal disorders. Intravitreal administration of each drug frequently causes rapid improvement of DME with sustained improvement in vision through 2 years. Though these drugs significantly outperform laser photocoagulation over treatment periods of 1 year of less, the advantages appear to lessen when trials approach 2 years. Further studies to better determine relative efficacies of anti-VEGF drugs and laser photocoagulation are continuing.

Dramatic Regression of Amelanotic Choroidal Melanoma With PDT Following Poor Response to Brachytherapy

Photodynamic therapy (PDT) has been used for treatment of choroidal neovascular membrane from exudative macular degeneration. Other applications include treatment of some intraocular tumors, such as choroidal hemangioma, vasoproliferative tumor, and choroidal osteoma. The authors report the effect of PDT for amelanotic choroidal melanoma. A 40-year-old woman with an amelanotic choroidal melanoma of 6.5 mm thickness showed poor response to iodine brachytherapy (80 Gy apical dose) with no reduction in thickness at 16 months of follow-up. There was prominent residual tumor. The amelanotic tumor was treated with verteporfin PDT using three overlapping spots (8,600 microns), with avoidance of the optic disc using standard treatment parameters. Dramatic tumor regression over 2 months to a completely flat scar (1.3 mm thickness) was documented and remained stable at 50 months of follow-up. Amelanotic choroidal melanoma with incomplete response following conventional plaque radiotherapy can be treated with verteporfin PDT for consolidation.

The effect of intravitreal bevacizumab injection in neovascular macular degeneration

BackgroundBevacizumab is a monoclonal antibody that binds vascular endothelial growth factor. It reduces angiogenesis and vascular permeability. In Italy it is approved for colorectal, lung, breast and renal cancer. In...

IDIOPATHIC POLYPOIDAL CHOROIDAL VASCULOPATHY (IPCV)

Eleven patients, 40 to 71 years old, had a choroidal vasculopathy that led to hemorrhagic and exudative macular degeneration. The patients had peculiar polypoidal, subretinal, vascular lesions associated with serous and hemorrhagic detachments of the retinal pigment epithelium. This macular disorder, which we have named idiopathic polypoidal choroidal vasculopathy (IPCV), appears to represent a distinct entity that differs clinically and demograph-ically from age-related macular degeneration (AMD) and other macular diseases associated with subretinal neovascularization. Recognition of this condition is important because it may have specific risk factors, natural course, and management considerations that differ from those of age-related macular degeneration

Aflibercept (VEGF-TRAP): The Next Anti-VEGF Drug

The inflammatory cytokine, vascular endothelial growth factor (VEGF), plays a central role in human growth and development, and vascular maintenance. VEGF mediated angiogenesis is essential for tumor growth, as well as exudative age-related macular degeneration, proliferative diabetic retinopathy and retinopathy of prematurity, all of which are characterized by abnormal neovascularization. Ischemia and inflammation also lead to VEGF-mediated breakdown of the blood-retinal barrier, which causes vision diminishing macular edema. To combat these effects, anti-VEGF drugs (antibodies, aptamers, and tyrosine kinase inhibitors) have been developed for both systemic and local (intraocular) use. The next drug to receive regulatory approval will probably be aflibercept (VEGF-Trap), a fusion protein with high VEGF affinity attributed to binding sequences from the native receptors VEGFR1 and VEGFR2. Aflibercept monotherapy significantly reduces tumor growth and extends survival in several orthotropic animal models, and has both prevented and reduced the growth of experimental choroidal neovascularization. Ongoing phase III trials are evaluating the effectiveness of aflibercept combined with chemotherapy in patients with advanced carcinomas. The phase III VELOUR trial determined that patients receiving aflibercept with irinotecan/5-FU as second line chemotherapy for metastatic colorectal cancer experienced extended progression free survival and overall survival. Intravitreal aflibercept improved visual acuity in patients with exudative age-related macular degeneration and was non-inferior to standard therapy (ranibizumab). Ongoing phase III trials are investigating the use of aflibercept for retinal vein occlusions and diabetic macular edema. A regulatory approval application for use in exudative macular degeneration has been filed, with a decision expected by late 2011.

Prevalence of early and late stages of physiologic PVD in emmetropic elderly population

To investigate the early and late stages of posterior vitreous detachment (PVD) in the foveal area in correlation with age and gender. Three hundred and thirty-five emmetropic eyes of 271 Caucasian patients (216 women/119 men) were examined by optical coherence tomography (OCT) and ultrasound (US). Eyes were classified into groups according to the patients age (up to 69.9; 70-74.9; 75-79.9; over 80 years) and to the clinical findings [Vitreous state: Detached in US; Detached in OCT; Foveal adhesion (FA); Attached vitreous]. The mean age was 76 ± 8 ranging from 44 to 89 years in female and 72 ± 10 ranging from 46 to 87 years in male subjects. The vitreous was attached in 32% of all eyes, 18.5% had FA, 18.5% were detached in OCT and 68% were detached in US. While prevalence of FA decreases with increasing age, OCT-diagnosed detachments did not change significantly with age. Between the ages of 70 and 75, an increase in PVD rates occurred. The prevalence of PVD was similar in both genders. Women were significantly older than men in the late-stage PVD in the eyes. The use of OCT and US enabled us to detect a partial or total PVD in 80% of the eyes. A sudden increase in late-stage PVD between the ages of 70 and 75 was observed, correlating with the reported age prevalence of various macular diseases. In contrast to myopics, both genders of elderly emmetropics have a similar prevalence of PVD.

Paraoxonase phenotype distribution in exudative age related macular degeneration and its relationship with homocysteine and oxidized low density lipoprotein

Paraoxonase phenotype distribution in exudative age related macular degeneration and its relationship with homocysteine and oxidized low density lipoprotein

Correlation between exudative age‐related macular degeneration and pseudoexfoliation syndrome

AbstractPurpose To evaluate the correlation between exudative age related macular degeneration (AMD) and pseudoexfoliation syndrome (PEX) in patients receiving Bevacizumab therapy for AMD.Methods Consecutive 200 patients with exudative AMD treated with Bevacizumab at Vilnius University Hospital between December 2010 and March 2011 were included into the study. Each patient’s data was recorded only once. Those with retinal occlusive disease were excluded. The results were statistically analysed by SPSS 19.0 program.Results 135 (67.5%) females and 65 (32.5%) males were studied. The mean age was 73.9 (SD=0.6) years. The difference between the mean age of female and male patients was statistically not different (74 and 73.3 years respectively). The prevalence of PEX in the treated as well as in the controlateral eye was 15.5% (31 patients), binocular PEX was in 32% of the eyes, in all there were 15.0% eyes with PEX. There was no statistically significant correlation between the type of AMD and frequency of PEX, but the frequency of PEX in eyes with AMD was twice larger than in controlateral eyes without AMD: Odds ratio was 1.96 (95% CI: 0.4‐8.6). No correlation was found between sex, AMD type and PEX.Conclusion In our study exudative AMD was found more often in female patients. PEX was found more often in eyes with AMD. No statistically significant differences between frequency of PEX and type of AMD were found. Further studies are necessary to achieve statistically significant results.

Early Perfusion of a Free RPE–Choroid Graft in Patients with Exudative Macular Degeneration Can Be Imaged with Spectral Domain–OCT

To study early flow and revascularization in a free, autologous, retinal pigment epithelium (RPE)-choroid graft. This prospective cohort study used spectral domain-optical coherence tomography (SD-OCT) after RPE-choroid graft surgery in 12 patients. This SD-OCT was combined with fluorescein angiography (FA) and indocyanine green angiography (ICGA) in 5 patients. SD-OCT revealed that vessel diameter, number of vessels, and graft thickness increased in 10 of 12 patients, starting between 3 and 10 days after surgery. A subsequent decrease in thickness was found in all 10 patients, beginning as early as 8 days after surgery. Initially, the graft vessels were optically clearer than the underlying choroidal recipient vessels. Between 8 and 30 days after surgery, the optically clear vessels became gray, similar to the recipient choroid. FA and ICGA revealed perfusion in 4 of 5 patients between postoperative days 6 and 15. Between postoperative days 12 and 60, the entire choroidal structure of the graft was visible on ICGA. CONCLUSIONS; These data suggest that enlargement of vessel diameter, increase in the number of choroidal vessels, and graft thickening visualized by SD-OCT correspond with the ingrowth of afferent vessels, as demonstrated by ICGA. The subsequent establishment of efferent vessels results in flow, imaged as a change in color of the graft's vessels from optically clear to gray, graft thinning on SD-OCT, and complete revascularization on ICGA. SD-OCT, a noninvasive examination, can be used to demonstrate early graft perfusion in patients (trialregister.nl/trialreg/admin/rctview.asp number, NTR1768).

The ocular pulse amplitude at different intraocular pressure: a prospective study

To investigate changes in ocular pulse amplitude (OPA) during a short-term increase in intraocular pressure (IOP) and to assess possible influences of biometrical properties of the eye, including central corneal thickness (CCT) and axial length. In a prospective, single centre study, OPA and IOP as measured by dynamic contour tonometry (DCT) were taken before baseline- and post-OPA (delta) intravitreal injection of 0.05 ml anti-vascular endothelial growth factor agents. Analysis was performed employing linear regression with baseline- and post (delta)-OPA differences as the dependent and post-IOP as well as delta IOP as the independent variable. A multilinear regression analysis with delta OPA as the dependent variable and baseline IOP, post-IOP, CCT and axial length as independent variables was conducted. Forty eyes of 40 patients were included. IOP and OPA increased significantly after injection (IOP mean increase ± SD: 17.83 ± 9.83 mmHg, p < 0.001; OPA mean increase ± SD: 1.39 ± 1.16 mmHg, p < 0.001). For every mmHg increase in IOP, the OPA showed a linear increase of 0.05 mmHg (slope 0.05, 95% CI: 0.02-0.09, p = 0.003, r(2) = 0.20). Multiple regression analysis with delta OPA as the dependent variable revealed a partial correlation coefficient of 0.47 (p = 0.003) for post-IOP as the only significant contribution. A clear positive relationship between OPA measurements and IOP levels was shown in a clinical routine setting using DCT focusing on baseline and postinterventional comparisons of OPA values after intravitreal injections in patients with exudative age related macular degeneration. When considering the OPA for diagnostic purposes, we recommend indication of corresponding IOP values.

Macular Pigment Density Measurement in Patients with Age-related Macular Degeneration

Macular pigment is key to the healthy eye. Direct determination of macular pigment optical density using single-wavelength reflectometry with a fundus camera has allowed to identify changes in macular pigmentation in patients with dry or exudative macular degeneration. This approach could be useful for individualised patient follow-up, particularly in those with age-related macular degeneration.

Macular Edema: Miscellaneous

This article provides the reader with practical information to be applied to the various remaining causes of macular edema. Some macular edemas linked to ocular diseases like radiotherapy after ocular melanomas remained of poor functional prognosis due to the primary disease. On the contrary, macular edemas occurring after retinal detachment or after some systemic or local treatment use are often temporary. Macular edema associated with epiretinal membranes or vitreomacular traction is the main cause of poor functional recovery. However, the delay to observe a significant improvement of vision after surgery should be long, as usually observed in tractional myopic vitreoschisis. Finally, some circumstances of macular edemas such as hemangiomas or macroaneurysms should be treated, if symptomatic, with the treatments currently used in diabetic macular edema or exudative macular degeneration.

Vitrectomy for Treatment of a Lamellar Hole in a Patient with Exudative Macular Degeneration: The Role of Vitreous Traction Elimination

Lamellar macular hole (LMH) represents a well-defined clinical entity with variable pathophysiologic mechanisms and a controversial therapeutic approach. The purpose of the present work is to present a patient with an epiretinal membrane (ERM)-associated LMH on the background of exudative age-related macular degeneration (AMD) that was successfully managed with pars plana vitrectomy. Interventional case report. A 67-year-old man presented with progressive visual loss OS of 5 months' duration. He was diagnosed with an ERM-associated LMH with coexisting subretinal fluid arising by a neovascular membrane on the background of exudative AMD confirmed with fundus fluorescein angiography. He underwent a 3-port pars plana vitrectomy with ERM-internal limiting membrane peeling and gas tamponade (14% C3F8) for treatment of the LMH and ERM with a view to undergo anti-vascular endothelial growth factor treatment for the exudative AMD. Postoperative optical coherence tomography demonstrated complete closure of the LMH with simultaneous total subretinal fluid absorption that was maintained at the 2-month follow-up period. To our knowledge, this is the first report whereby pars plana vitrectomy in a patient with an ERM-associated LMH on the background of exudative AMD resulted in improvement of both clinical entities. The latter strengthens the role of vitreous traction elimination in exudative AMD and highlights the need for further research.